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Dispatch follow-up

Rhabdomyolysis laid low 6 athletes

Request to buy this photoNeal C. Lauron | DISPATCHKelly Becker and her parents, Betsy and Bill Becker of Dublin, have pressed Ohio State officials to develop a more-thorough report of the incident that hospitalized Kelly and to make it public.

Request to buy this photoNeal C. Lauron | DISPATCHKelly Becker spent several days in intense pain in Ohio State University’s Wexner Medical Center. Her bout with rhabdomyolysis left her weak for months.

Request to buy this photoJIM SLOSIAREK | SOURCEMEDIA GROUP NEWSOn Jan. 26, 2011, Paul Federici, the University of Iowa’s director of football operations, described the hospitalization of 13 football players who had developed rhabdomyolysis.

Almost immediately after enduring a new, intense workout on a Tuesday afternoon last March, Kelly Becker began to understand that she and her Ohio State women’s lacrosse teammates had not performed just another conditioning drill.

Becker’s arms were shaking and weak, with a prickly, tingling sensation that left her unable to write or lower her arms to her side. A day later, before and after a bad practice, her arms hurt so badly that she could barely shift gears in her car or turn the steering wheel.

That night and the next, Becker tossed and turned because of pain and swelling in her arms. By Thursday, her urine had turned brown like cola.

"I knew absolutely that something was wrong," she said.

On that Friday one year ago today, Becker showed up to practice with the Ohio State women’s lacrosse team and was asked to provide a urine sample, same as all of her teammates who had taken part in the intense workout.

Becker then was sent to the emergency department at Ohio State’s Wexner Medical Center and told she was suffering from exertional rhabdomyolysis, a potentially harmful condition commonly known as "rhabdo."

"I had never heard of rhabdo," said Becker, a 21-year-old Dublin native.

Five of her teammates — Caylee Rafalko, Olivia Annalora, Taylor Donahue, Cara Facchina and Tayler Kuzma — also were sent to the ER with rhabdo. Five of the six were admitted, and Becker was there for four nights.

Ohio State has never released details about the workouts that landed the players in the hospital, nor has the university said which players were affected, but experts on rhabdomyolysis say the incident should have been prevented — the same as any other rhabdo case affecting any other athlete anywhere.

"That type of injury is 100 percent avoidable," said Jay Hoffman, president of the National Strength and Conditioning Association from 2009-12. "That should never have happened. That’s absurd. People need to understand that rhabdo is not inherent with training. It’s a good indicator of a training program that is inappropriate."

An Ohio State committee investigated the incident and made recommendations that included more education about rhabdo for all members of the university’s 36 varsity sports programs. But three families of the six hospitalized players have implored OSU President E. Gordon Gee to have the university do more.

Teaching the general public how to recognize symptoms and prevent rhabdo is why Kelly Becker’s parents have spent the past year asking OSU to publish a full report about the incident involving the women’s lacrosse team.

"We’re not interested in filing a lawsuit," said Bill Becker, an attorney in the Ohio Attorney General’s office. "As we’ve said all along, we’re interested in making sure good things come out of this so it doesn’t happen at other universities or high schools, or to anybody playing sports. The only way that’s going to happen is if there is a published case history of this particular incident so everybody knows about it and everybody can learn from it."

Rhabdomyolysis, an ailment long known in the medical community, occurs when muscle fibers break down, releasing myoglobin into the bloodstream. Myoglobin is harmful to the kidneys and can cause kidney damage.

"There are two reasons why this is important," said Kelsey Logan, a university-affiliated physician who serves on the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. "One is that rhabdo can have potentially serious consequences: renal failure, compartment syndrome, death. Those are fairly serious.

"And the second thing is we know there are certain circumstances under which this is more likely to occur, and with fairly simple educational and practical techniques for prevention, those circumstances can be lessened so much."

Incidents of rhabdomyolysis share a common theme.

"It could be referenced as overuse syndrome," said Scott Anderson, head trainer at the University of Oklahoma and a leading expert on rhabdo as president of the College Athletic Trainers’ Society. "It’s typically going to occur from doing too much of a novel type of exercise. Too much of it is done in too short of a period of time without some acclimation of progressions."

In the Ohio State case, Kelly Becker told university officials that on March 6, 2012, the women’s lacrosse players performed a series of grueling upper-body workouts unlike anything they had done to that point in the season. The workout included pull-ups (she did 56), chin-ups and triceps-crunching dips without rest during a 20-minute workout. Two days later, they pushed football blocking sleds. The six players went to the hospital the next day.

"Because (rhabdo) is rare, and coaches or trainers have not seen it, they can’t understand how they caused it," said Priscilla Clarkson, a leading expert on rhabdo as an exercise science professor at the University of Massachusetts.

Perhaps the most publicized case of rhabdomyolysis occurred in January 2011, when 13 football players at the University of Iowa were hospitalized after an offseason conditioning session. Other known cases of rhabdo include:

* At the University of South Carolina, seven members of the men’s and women’s swim teams required hospitalization six years ago, prompting an inquiry by the state’s public department of health.* In Oregon, 22 high-school football players were hospitalized after a conditioning session in 2010. Thirteen were admitted, and three underwent surgery after suffering tricep compartment syndrome, an Oregon Public Health investigation reported.* In Virginia, a high-school football player underwent seven surgeries on his arm for acute compartment syndrome after he and four teammates were hospitalized after a conditioning session in 2011.

"There’s an under-appreciation for these cases," said Anderson, head trainer at the University of Oklahoma. "There’s an under-reporting of these cases. There’s a lack of awareness. Events continue to occur."

In addition, The Dispatch has learned from documents that three players on the Miami University women’s soccer team were hospitalized — at least one for four days — with rhabdomyolysis in August 2011 after two days of preseason workouts.

And at the University of Maine, five cases of rhabdo, unreported by the media, occurred in 2012 among members of football team, according to sources. A Maine official refused to confirm, deny or comment the report when contacted by The Dispatch.

Ohio State discussed the women’s lacrosse team incident in a news conference three days after the hospitalization of its players. At the time, two players had been released and four remained in fair condition at Wexner Medical Center.

"They’re all fine, and we don’t anticipate any long-term significant consequences," said Dr. Chris Kaeding, the head physician for the OSU athletic department.

That week, the parents of Becker and Rafalko told Heather Lyke Catalano, an OSU associate athletic director, that they wanted an investigation with root-cause-analysis findings published, just as Iowa had produced in 2011.

"What we’ve asked to be done — make a public record of this case — is perfectly reasonable," Bill Becker said. "It’s fair. It’s the right thing to do. With Ohio State and all the resources it has, why did they not step up here? Why did they not take a leadership role? Why did they not say, ‘OK, we can make a difference here’?"

OSU makes changes

Ohio State athletic director Gene Smith’s initial reaction last year to hearing that six lacrosse players were hospitalized because of rhabdomyolysis was concern — for the students and the training program.

"Besides the care of the student-athletes who were affected immediately, I wanted us to begin to implement education across to our strength coaches, our trainers, our coaches, and our athletes," Smith said.

After Iowa’s 2011 incident, OSU had conducted education sessions about rhabdo with its trainers and strength-and-conditioning coaches. Still, a case occurred among the Buckeyes 14 months later.

"It made us look at our communication," said Janine Oman, an OSU assistant athletic director who oversees the university’s sports medicine care as director of sports performance. "How can we provide better education among the entities so we’re looking at things more holistically than on individual levels?"

Since Ohio State’s outbreak, the university has expanded its education about rhabdomyolysis to all of its sports coaches and athletes with email blasts of information and Internet links about the topic. Posters detailing the condition and its symptoms were placed in athletic facilities. In August, OSU trainers discussed rhabdo during their annual presentation to each team.

Unlike in the Iowa incident, OSU tested all of its lacrosse players for rhabdo after an initial player, Rafalko, reported discolored urine.

"That was one thing we learned from (Iowa)," Oman said.

Iowa’s incident was detailed in an 18-page report from an investigation ordered by university president Sally Mason and Board of Regents president David Miles, who said in a joint statement that the football players’ hospitalization was a "cause for grave concern." Iowa presented its report, prepared by a five-member committee of faculty and staff appointed by Mason, to the Board of Regents two months after within a month of the January 2011 case.

"If there’s any good that came out of our deal, it’s that people learned a lot about it," Iowa football coach Kirk Ferentz said.

Iowa team physician Kyle Smoot has since written an analysis of the incident and said this week it will be published in the Clinical Journal of Sports Medicine.

"We thought it was important to educate everyone since we’re an academic institution," Smoot said. "We figured if it happened here, it could happen at other athletic programs."

After three weeks of interviews with 15 people, including women’s lacrosse coach Alexis Venechanos, the committee produced a four-page document that Oman said was prepared by the OSU legal department.

"I thought it was well-done," Smith said. "It was thorough. It was a report that allowed us to address our issues and move forward. Obviously, we looked back at what occurred and we ultimately had to respond to that. I felt good about the report."

The OSU report includes a timeline of events leading up to the hospitalization, reasons why "the incident likely happened," and recommendations for increased education and prevention. Suggestions for university outreach on rhabdo were outlined, but did not include the report’s publication.

"We have these medical cases in a lot of different things and we don’t publish all those reports," with medical situations," Smith said. "We deal with the student-athletes involved. We educate our people. When we have medical issues, we study them, and we may create a report and we may not. But we don’t do a publishing of it.

"This particular injury had been covered significantly by the University of Iowa. It was discussed significantly at the NCAA level early on, and I think we’re starting to see the results of those discussions occurring. So we treated it like we treat other medical conditions or injuries: How do we get better relative to Ohio State University?"

Asked whether OSU could help educate the public with a published report, Smith said: "We’d be doing public reports all the time."

The Beckers requested and received a copy of the report from Ohio State last June and said they were dismayed by its brevity. The family then gave a copy to Dr. David Rafalko, who performs root-cause analyses of medical cases and asked OSU to do so on behalf of his daughter.

"This (report) was done as some sort of pro forma because it had to be done, but this is not going anywhere," said Rafalko, the director of patient safety at the Heritage Valley Health System near Pittsburgh. "In the end, I think their main concern was to really not allow the knowledge of it happening to disseminate outside the institution."

The families, along with the mother of hospitalized player Olivia Annalora, then wrote to Gee in July. Their letter said the university’s report was "inadequate" because it didn’t detail the specific exercises performed, offered no lesson plan for future prevention, and wasn’t published.

Jeff Kaplan, a senior vice president at Ohio State, responded in August with a letter to the Beckers saying, "we believe that the report and recommendations are sufficiently public and informative" and that the university had "produced the report on numerous occasions" in the past with more plans to do so.

Illness hits some hard

Experts say rhabdomyolysis typically is mild but has the potential to be dangerous because it affects individuals differently for reasons as varied as personal physiology.

Kelly Becker learned the hard way.

During her four nights at the Wexner Medical Center, she was given the pain medicines oxycodone, Dilaudid and tramadol. Becker’s arms swelled so much that she needed an anti-clotting injection. She also suffered intense headaches and dizziness.

"It’s hard to hear someone say you’re going to be fine when you’re in the most excruciating pain of your life," Becker said. "Everything was painful."

The other five hospitalized players returned to play last season. Rafalko and Annalora have since graduated and could not be reached for comment. Donahue, Facchina and Kuzma remain on the team but declined interview requests. So did Venechanos.

Upon her release from the hospital, Becker went to her family physician for more pain medicine.

"When I got home, I couldn’t walk down the street," Becker said. "I had to walk with people. I couldn’t straighten my arms. It was weeks before I could raise my arms above my head. I didn’t start running until after a couple of months. I didn’t lift a weight for four months."

By then, Becker had decided to transfer from Ohio State and was granted a medical hardship by the Big Ten. She’s now a member of the University of Michigan lacrosse team, which begins varsity play next year.

Also departed from OSU is Tom Palumbo, the strength-and-conditioning coach for the women’s lacrosse team who had worked with other OSU teams since 2001. Ohio State fired him on May 4, eight weeks after the incident, even though the school’s report did not mention wrongdoing or disciplinary action for anyone.

"The blame has to go somewhere," said Palumbo, now the strength-and-conditioning coach at Flagler College in St. Augustine, Fla. "I asked them why and they would not tell me why I was being fired. They don’t have to because I was an at-will employee, and that means they can fire me anytime, for any reason."

Smith and Oman declined comment when asked about Palumbo’s firing.

"I don’t discuss personnel matters," Smith said.

In the meantime, word of the OSU lacrosse incident is making its way into various sports-medicine journals and handbooks.

The NCAA doesn’t require schools to file reports of such incidents. In doing her own research, Kelly Becker noticed that the condition isn’t mentioned in the NCAA Sports Medicine Handbook, so last spring she contacted Dr. Randy Eichner, a leading rhabdo expert now retired in California, about that oversight.

About the same time, OSU asked Logan of the Wexner Center to inform the NCAA Safeguards Committee about the lacrosse team’s incident. She did not write a formal report but reviewed the case in conversation and email.

Last June, the NCAA Safeguard Committee said that Eichner, who has interviewed the Beckers, could write two chapters about rhabdo for its sports-medicine handbook.

"We’re focusing on awareness, education and prevention," said Dr. David Klossner, NCAA director of health and safety. "People involved, and the athletes, should know what rhabdo is, how to recognize it and prevent it."

Logan expects the new chapters to be approved when the Safeguards Committee meets in June and included in the new edition of the handbook this summer.

"It’s great that the NCAA is making this a focus," Logan said, "so that institutions can point to it when they’re trying to educate their strength-and-conditioning coaches and when they’re trying to educate their student-athletes."

Additionally, Dr. James Borchers, the physician assigned to the OSU women’s lacrosse team, is scheduled to talk about the OSU rhabdo case at the Big Ten’s annual Sports Medicine Meeting in May. He also is writing an article on the case for the Sports Health Journal.

The Beckers still look for more, and Smith said he’s sensitive to their complaints, but "we feel very comfortable that our response was appropriate and consistent with the response we’ve had with other medical issues."

Last month, the Beckers wrote a letter to the NCAA asking the organization to consider rules and possible sanctions for schools that have athletes hospitalized because of rhabdomyolysis.

2012 — Five members of the University of Maine football team developed rhabdomyolysis, though it was not reported by the media, multiple sources say. A Maine official refused to confirm, deny or comment on the report when contacted by The Dispatch. August

2011 — Documents show that three members of the Miami University women’s soccer team were hospitalized after two days of conditioning sessions that included pull-ups, chin-ups, push-ups and bench presses with dumbbells while lying on an exercise ball. The incident was not reported. Miami investigated the matter and made recommendations for guidelines and further education. May

2011 — Five football players from Wooton High School in Virginia were hospitalized, one for 19 days, after performing triangulated push-ups during a conditioning session. The school investigated and discontinued that specific drill.

January 2011 — Thirteen members of the University of Iowa football team were hospitalized four days after the team underwent a conditioning session that included the completion of 100 back squats using weights. Players also performed barbell snatches, pull-ups, dumbbell rows and a weighted sled-pushing exercise. A university committee investigated the incident and published an 18-page report that found no wrongdoing by coaches but recommended that an “intense, high-volume squat-lifting workout” be discontinued.

August 2010 — Twenty-two members of the McMinnville, Ore., High School football team were taken to the hospital, and 13 were admitted, after a conditioning session in which repetitive, intensive chair-dips and push-ups were performed inside a small room on a 92-degree day. Three of the stricken players had to have surgery on their arms because of triceps compartment syndrome.

August 2010 — Washington Redskins defensive lineman Albert Haynesworth missed three days of practice during training camp because of rhabdo. He told reporters the team was underplaying the severity of his condition after Redskins coach Mike Shanahan described the player’s condition as being “more of a headache than anything else.”

October 2009 — Donnie Wade Jr., 20, of Dallas, died during an intense physical-training session during a fraternity hazing ritual at Prairie View A&M University. Wade collapsed during a drill, and the Harris County medical examiner attributed his death to “acute exertional rhabdomyolysis.” The family’s wrongful-death lawsuit alleged that Wade was deprived of fluids while undergoing exercises that included running bleachers, leg lifts, pushups and jumping jacks. Prairie View A&M disbanded the fraternity chapter.

September 2007 — Seven swimmers (four men and three women) at the University of South Carolina were hospitalized after a workout that reportedly included as many pushups as they could do in a minute followed by 60 seconds of squats — a sequence repeated for 10 minutes. One swimmer said they were being asked to exercise “to failure,” meaning to keep going until their muscles gave out.